ERCP is widely used diagnostic and therapeutic method in the management of biliary tract and pancreas. Some complications of the procedure, although rare, can have significant morbidity and mortality risk [
]. We describe a lasix generic rare case of bilateral pneumothorax complicating ERCP in the presence of abdominal extraluminal air. 2. Case Presentation
68-year-old patient was accepted as an elective patient duct stone clearance under midazolam sedation. Previous extraction failed due to the size of stones while sphincterotomy with biliary stent was performed. Repeated ERCP, sphincterotomy was extended and the two calculations have been removed. Immediately postprocedure, the patient became profoundly hypoxic and tachypnoeic. Medical examination revealed large subcutaneous emphysema and poor air entry bilaterally. The patient was transferred to the HDU, where chest X-ray revealed large bilateral pneumothorax and pnevmomediastinuma (Fig.
). Abdominal imaging (X-ray) showed evidence of further lumen air pneumoperitoneum and pneumoretroperitoneum. The patient was stabilized with bilateral chest drain insertion and made a rapid recovery (Fig.
). Treatment with antibiotics is required, except for one unit, which is empirically introduced immediately after the procedure. On the third day of admission, pneumothorax completely resolved (Fig.
) and chest drains were removed. The patient was discharged the next day. 3. Case Discussion
Only three cases of bilateral pneumothorax complicating ERCP are described in the literature []. Unilateral pneumothorax, though rare, has been described in several cases. In all previous reports, the presence of air in the pleural cavity is accompanied by pneumoperitoneum, pneumoretroperitoneum and pnevmomediastinuma. The proposed mechanism of leakage air clearance by keeping track of the retroperitoneal space in the abdominal cavity, pleural cavity, mediastinum and subcutaneous tissue. Distribution of air is possible through the deep fascial planes [
], but the porous diaphragm syndrome also has been described recently [
]. The most common reason for leakage of air in the lumen ERCP is duodenal perforation [
], but any site with a low resistance, as an ulcer or tumor can serve as a valve during insufflation. [
]. Three different types of ERCP-related perforations are described: (a) conductor associated perforation, (b) periampullary perforation during sphincterotomy, and (c) perforation, distant from the papilla [
]. The above pathophysiological mechanisms may explain the totality of symptoms and the results described in this case as a result vnutryprosvetnoho air escaping into the abdomen. The process underlying issue vnutriprosvetnyy air can be explained by the clinical picture. The patient made a surprisingly quick recovery after chest drain insertion and remained completely asymptomatic until discharge. Only one dose of antibiotics administered. Pneumothorax pnevmomediastinuma, pneumoretroperitoneum and pneumoperitoneum was fully resolved on the third day of admission without further intervention. This rapid clinical improvement would not be expected in case of perforation of duodenum in the duodenoscope. In most cases perforation after ERCP, distant from the nipple (esophagus, stomach, duodenum), require surgical intervention. All cases were symptomatic and required antibiotics [
]. Based on clinical presentation and limited regards the patient, who refused to cross tomography esophagus, stomach or duodenal ulcer perforation was excluded on the basis of clinical picture. Although no additional imaging was obtained due to limitations case, we believe that the investigation of choice to exclude perforation will be crossing the imaging study of the abdominal cavity, which should always be part of the diagnostic in such cases, when possible. Rapid clinical improvement of the patient may be better explained by a small air leak arising from the site of low resistance, which in this case is likely to be sphincterotomy site or conductor associated perforation. However, we note that most reported cases of sphincterotomy or guide related perforation is symptomatic and require broad-spectrum antibiotics, biliary tract and duodenal decompression [,,,
]. There is a second possible explanation for the mechanism that leads to patient presentation and results. This is based on our clinical observations during the procedure. In leakage sphincterotomy after onset of symptoms, is expected to be severe, but gradually over several minutes as the air gradually migrates from the abdominal cavity in the chest. However, in the case described here, and subcutaneous emphysema and pneumothorax seen hyperacutely more seconds. In the previous period, the patient really wanted to exaggerated reactions of respiratory and continuous vomiting during the procedure. We believe that patient response was equivalent to an intensive and continuous Valsalva maneuver. Valsalva was closely associated with the development of subcutaneous emphysema hiperostroy, pnevmomediastinuma, rarely pneumothorax [
]. We believe that the air escape in the mediastinum and pleural space may use the same way as described above, through the deep fascial planes or diaphragmatic pores migrate in the abdomen, explaining the presence of extraluminal air. Clinically, the patient will be represented by a combination of subcutaneous emphysema, pneumothorax, pnevmomediastinuma, pneumoretroperitoneum and pneumoperitoneum. 4. Conclusion >> << Combining our observations with previously existed theory, we believe that pneumothorax, pnevmomediastinuma, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema during ERCP in the absence of perforation of the duodenum, can be explained by leakage of air from the low resistance such as sphincterotomy site or by Valsalva maneuvers performed abundant patient tolerated the procedure poorly. .
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